Types of Treatment - Conventional Facilities
Conventional Facilities for treating Brain Injuries
Level I Trauma Center
A level I trauma center is a facility that is equipped with the proper equipment and staffed with the right specialists in order to provide comprehensive emergency services to people who have suffered one or more traumatic injuries. Level I trauma centers have arisen out of a need for specialized and urgent care for those who have sustained a trauma. It requires a multidisciplinary approach with many specialties involved. Accidents and other traumas are common.
They are the leading cause of death for Americans from age 1 to age 44. People tend to suffer from injuries secondary to motor vehicle accidents, falls and assaults with dangerous weapons.
Trauma centers are declared level I by the state in which the hospital resides and are verified by the American College of Surgeons (ACS) by passing a site review by a special verification review committee. A level I trauma center has the highest capability to handle traumas above all other hospitals. Level I trauma centers are equipped with trauma surgeons available 24 hours a day as well as doctors in other specialties such as neurosurgery, maxillo-facial surgery, an orthopedic surgery and nursing specialties.
These centers will have extremely sophisticated medical equipment and can admit trauma patients to a critical care unit for trauma victims.
Level I trauma centers generally have a helipad to receive helicopter transports from a wide area of smaller hospitals that aren’t equipped to handle severe emergencies. Helicopter transports are much faster and provide better care than ground transports. The level of trauma certification can significantly affect the patient’s care and outcome so for seriously traumatized patients, it is best to use a level I trauma center, even if it is a distance away.
Trauma centers actually began in England in 1941 during the war when it became apparent that the treatment of trauma patients was not adequate. The first hospital to be declared a trauma center was the Birmingham Accident Hospital. By 1947, they had a burn team that housed three surgeons. It eventually closed in 1993. The idea of being a shock trauma center was developed in Baltimore at the University of Maryland in the 1950s and 60s. The Shock Trauma Center in Baltimore, Maryland, opened in 1960 It is the oldest such facility in the world. . The second hospital to be declared a shock trauma center was the Cook County Hospital in Chicago, opening in 1966. Numerous hospitals in the US claim to be trauma centers but do not have a verified level I status as identified by the American College of Surgeons. A state can declare a facility a level I facility but unless it is verified, it may not have all of the necessary qualifications of a verified level I trauma facility.
There are approximately 107 verified level I trauma centers in the US with an additional 96 not being verified. Level I trauma centers provide the greatest level of surgical care to trauma victims and being treated at one increases the survival chances of a patient by 20-25 percent. These centers see a minimum number of trauma patients per year in order to keep their certification. They must also do research in trauma care and be a leader in the education of doctors and the public on injuries and injury prevention.
Intensive Care Units (ICU’s)
An intensive care unit is also called an ICU or an intensive treatment unit (ITU) or a critical care unit (CCU). It is a place where the patients are the sickest and require the most attention from a critical care team. The patients have the most life-threating and severe illness and traumatic injuries that require constant attention and monitoring using specialist equipment that monitor the patients’ vital signs and support the patients who need ventilator care or other supportive equipment.
The most common patients seen in the ICU include trauma patients, multiple organ failure patients , and sepsis. Serious patients who are treated in the emergency room might be transferred immediately to the ICU for care or might be on a regular patient ward and deteriorate, necessitating transfer to the ICU. Some patients are post-operative patients who had a very invasive surgery or who had a difficult time recovering from the surgery in the surgical ward or directly from the operating suite.
Intensive care units and the idea of intensive care came out of the 1950s when an anesthesiologist first created the idea of keeping patients who were sedated and on a ventilator in a separate intensive care environment. He later practiced intensive care medicine and created it as a new specialty. The first intensive care unit was created in Europe in 1953 and later in the US in 1955. In the 1960s doctors recognized the importance of cardiac arrhythmias and developed cardiac monitoring in the ICUs, especially if the person was high risk, such as having a myocardial infarction.
There are several different types of intensive care units that are catered to different kinds of patients with different problems. These include:
The trauma ICU is found only in level I trauma centers. They have a specialized trauma emergency department that is staffed round the clock with trauma surgeons, emergency medicine specialists, neurosurgeons and other practitioners needed to treat urgently seriously injured patients.
In the Neuro ICU, patients are treated for Parkinson’s disease, strokes, aneurysms, brain tumors and patients who have recently had difficult neurological surgery. Specialty neurological nurses staff this kind of ICU.
There is often a PACU or Post-anesthesia Care Unit in larger hospital. This is for patients who have recently had surgery and need intensive observation or stabilization following their surgeries.
Often they need to reach certain physiological criteria before they can be transferred to a regular surgical ward.
Some hospitals have a SICU or surgical intensive care unit, which provides care for critically ill patients who have just had surgery. Surgeons and specialty surgical nurses staff this unit.
Most patients in an ICU have one on one nursing care because they are unstable or are on mechanical ventilation. The nurse is usually specially trained to manage these types of patients in conjunction with hospitalists and intensive care doctors. Hospitalists are specially trained in treating patients who are in the hospital and do not work outside of the hospital. They generally care for the sickest patients in the hospital in conjunction with the patient’s regular physician.
Equipment Used in Intensive Care
Persons treated in the ICU may be unconscious, in a coma, and medically unstable. Many tubes, wires, and pieces of medical equipment may be attached to the patient to provide life sustaining medical care.
Patients treated in an intensive care unit or ICU are often “hooked up” in a variety of ways. Some equipment is designed to monitor the patient’s vital signs and physiological parameters while other equipment is used directly to treat or support the patient.
A common piece of equipment used in an ICU is a mechanical ventilator. It is a relatively large machine that breathes for the patient, allowing air to pass from the machine through tubes and into the patient by means of an endotracheal tube. The ventilator can produce certain amounts of oxygen so the patient can be on “room air oxygen” or 100 percent oxygen.
The endotracheal tube is a specialized piece of equipment that involves a tube inserted through the vocal cords and into the trachea. A balloon around the endotracheal tube is inflated so air cannot escape around the tube and to help the tube stay in the trachea without falling out. An endotracheal tube is also called a tracheostomy tube. Some people have a tracheostomy tube, which is a tube that is inserted into a hole in the front of a person’s neck and into the trachea to help them breathe. Patients can receive IV fluids given by bags hanging above the patient’s bed. Fluid is directed through tubes to a small machine that can be manipulated to give a specific rate of fluid. The fluid goes to a catheter inserted into a vein. If a patient doesn’t have adequate veins a PIC line can be inserted into a vein above the elbow that goes eventually into the heart. It has several ports and has one port designated for the taking of blood so no extra “sticks” need to be done for blood draws.
In some cases a central line is inserted into a vein in the shoulder that is also threaded to the heart and can be used for people who do not have good veins.
The patient may have a nasogastric tube placed. This is a flexible tube inserted in the nose and passed through the nasopharynx and down to the stomach. It can be used to drain the stomach of its contents in patients who need it. More often, it is used to drip in a liquid nutrient for patients who are in a coma or are otherwise not able to eat on their own. It provides vitamins, protein and carbohydrates so that patients can receive some calories while they are in the ICU and unable to eat.
For the heart, there is telemetry. The patient who needs cardiac monitoring has leads placed on their chest that go to a machine that detects their heart rate and shows a picture of the electrical activity of the heart on a monitor. If the patient has a heart arrhythmia, it will be detected by the monitor and an alarm will go off, alerting the staff.
Some people have pacemakers that control the electrical activity of the heart and are set to a specific heart rate.
Beside the bed in patients at high risk for having their heart stop, there are defibrillators, which are machines that have paddles placed on the patient’s chest to send an electrical shock designed to start the heart.
Some patients need dialysis equipment. Dialysis involves a machine that takes bad things out of the blood and returns healthy blood. A patient with an overdose, for example, can have the drug dialyzed out of their blood faster than the kidneys can handle it and patients with poor kidneys can have help with a dialysis machine.
Some patients need a urinary catheter to drain their bladder. The nurse can monitor the patient’s intake and output so they know the patient isn’t losing too much fluid or holding onto too much fluid.
Many medications are used to help patients who are in an ICU. In particular, propophol is a drug that is used to create a medically induced coma in patients who are critically ill and would feel enormous pain and agitation if allowed to be awake. The coma allows them to recover faster with fewer complications.
ACUTE Rehab Facility
As early as possible in the recovery process, individuals who sustain brain injuries will begin acute rehabilitation. The treatment is provided in a special unit of the trauma hospital, a rehabilitation hospital or another inpatient setting. During acute rehabilitation, a team of health professionals with experience and training in brain injury work with the patient to regain as many activities of daily living as possible. Activities of daily living including dressing, eating, toileting, walking, speaking and more.
Acute Rehabilitation Facility Sometimes after a severe injury, the individual is medically stable and just needs to learn how to do the things they could do before the injury, such as walking, eating, sitting up by one’s self, and learning how to bathe oneself. Patients can also go to an acute rehabilitation facility if they have had a significant surgery or a debilitating disease from which they need to recover.
Acute care facilities involve a multidisciplinary approach to healing. Patients can see occupational, physical and speech therapy and are attended by physiatrists, who are specialists in movement problems and other doctors who attend to their medical needs. Doctors are available 24 hours a day as a patient can suddenly destabilize and need acute intervention.
For brain-injured patients, a neuropsychologist is usually handy to see if the patient needs added psychological or psychiatric management. They may do neuropsychological testing to see what level the patient is at upon admission and to follow their progress as their brain heals. Patients receive a great deal of therapy at an acute rehabilitation facility. They generally receive at least three hours of therapy a day, lasting 6-7 days per week.
Therapy can be individual to the patient or a group therapy session, depending on the group’s collective needs. Therapeutic recreation may be available which can involve patients using fine motor manipulation to make things or sometimes use large motor muscles to do a project together.
Respiratory therapy is given for those patients with residual lung problems.
Research studies have indicated that when a trauma patient chooses to attend a rehabilitation facility, it can greatly speed up their physical and mental functioning, leaving them at a much higher level of functioning than they were at when they were discharged from the acute care hospital.
Some patients choose a subacute care facility, such as a nursing home. They recover slower there because they only receive a few hours of therapy a day for fewer days a week. The focus is on care of the patient and not on rehabilitation.
The outcomes are better at an acute rehabilitation hospital than they are at a subacute program. Patients are more independent in their own cares when they spend more time practicing those cares at an acute rehabilitation facility. Look for a hospital that is accredited by the Joint Commission and the Commission on Accreditation of Rehabilitation Facilities.
There is special accreditation available for those facilities that provide specialty care in spinal cord injuries, stroke, general rehabilitation, and brain injury. Acute rehabilitation hospitals offer physical therapy, which is mainly concerned with large motor activities such as walking, sitting in a chair by oneself and getting in and out of bed by themselves.
There is also occupational therapy, which is generally concerned with small motor skills and activities of daily living, such as cooking, cleaning and toileting oneself.
Speech therapy helps a patient recover from brain-induced speech deficits. They also handle swallowing difficulties that can arise from long term ventilator use or from brain-induced swallowing deficits
When patients are well enough to participate in more intensive therapy, they may be transferred to a postacute rehabilitation setting, such as a residential rehabilitation facility.
The goal of postacute rehabilitation is to help the patient regain the most independent level of functioning possible. Rehabilitation channels the body's natural healing abilities and the brain's relearning processes so an individual may recover as quickly and efficiently as possible.
Rehabilitation also involves learning new ways to compensate for abilities that have permanently changed due to brain injury. There is much that is still unknown about the brain and about brain injury rehabilitation. Treatment methods and technologies are rapidly advancing as knowledge of the brain and its function increases.
Extended Care Facilities
Extended care means living in a facility that offers long term assistance with an individual’s medical needs or activities of daily living. Some people receive extended help at home while others use various types of facilities to receive their care. People of all ages, depending on their illnesses and injuries, might need a prolonged stay at an extended care facility.
There are different kinds of facilities as you’ll soon see. Extended care facilities can also be called nursing facilities or nursing homes. They can differ greatly in the quality of care and physical surroundings so, as a family, it is up to you to find information out about these facilities so your loved one receives the best possible care. How do you check for quality? First, you need to find facilities that have demonstrated quality care to state agencies and accreditors, and one that takes care of the kind of patients similar to your loved one. Staff needs to meet your needs and it has to be within your allotted budget. There are different kinds of long term care you need to think about. The first is home care given by friends, paid professionals, family members or a combination of these. You can do things like shopping and cleaning, helping with activities of daily living and even dressing your loved one.
Certain skilled care activities like nursing care or therapy are allowed by Medicare for a short period of time. You can consider various community programs such as meals on wheels, adult daycare, transportation and senior services. These allow patients to stay at home for a longer period of time with community services helping them get daily care, allowing also for some family respite. There are government programs that offer low-cost housing to people with low to moderate incomes.
Look into the Department of Housing and Urban Development (HUD) or state and local programs for this kind of housing. These programs provide things like meals, shopping, laundry services and shopping with residents living in their own apartment. Assisted living housing gives a resident 24 hour supervision, assistance with activities of daily living, and healthcare onsite. There are social and recreational activities offered throughout the week and residents are helped with medication, toileting, transportation, housekeeping and laundry.
Extended care facilities or nursing homes take over the care of people who cannot be cared for in the community or at home. Skilled nursing care is provided along with meals, activities, rehabilitation, supervision, and help with activities of daily living. They deliver different levels of services and you can find out how a prospective nursing facility rates in terms of staffing, quality of care and physical surroundings at a site called “Nursing Home Compare” at www.medicare.gov/nhcompare/home.asp.
It is a site created by the Centers for Medicare and Medicaid Services in order to help families make decisions around skilled care for their loved one. Also look for help from hospital discharge planners, doctors, social workers, case managers, family and friends. Visit different extended care facilities with a list of questions so you can be fully informed about your loved one’s care.
Patients who cannot tolerate intensive therapy may be transferred to a subacute rehabilitation facility. Subacute rehabilitation programs are designed for persons with brain injury who need a less intensive level of rehabilitation services over a longer period of time.
Subacute programs may also be designed for persons who have made progress in the acute rehabilitation setting and are still progressing but are not making rapid functional gains. Subacute rehabilitation may be provided in a variety of settings, often a skilled nursing facility or nursing home.
Day Treatment (Day Rehab or Day Hospital)
Day treatment provides rehabilitation in a structured group setting during the day and allows the person with a brain injury to return home at night.
Following acute, postacute or subacute rehabilitation, a person with a brain injury may continue to receive outpatient therapies to maintain and/or enhance their recovery. Individuals whose injuries were not severe enough to require hospitalization or who were not diagnosed as having a brain injury when the incident occurred may attend outpatient therapies to address functional impairments.
Home Health Services
Some hospitals and rehabilitation companies provide rehabilitation therapies within the home for persons with brain injury.
Community re-entry programs generally focus on developing higher level motor, social, and cognitive skills in order to prepare the person with a brain injury to return to independent living and potentially to work. Treatment may focus on safety in the community, interacting with others, initiation and goal setting and money management skills. Vocational evaluation and training may also be a component of this type of program. Persons who participate in the program typically live at home.
Independent Living Programs
Independent living programs provide housing for persons with brain injury with the goal of regaining the ability to live as independently as possible. Usually, independent living programs will have several different levels to meet the needs of people requiring more assistance and therapies as well as those who are living independently and being monitored.